This study included 365 patients undergoing radical cystectomy with cutaneous ureterostomy urinary diversion (CUD) at 10 centers in Italy and Spain between 2011 and 2017. The primary outcome was the rate of 30-day complications. The type and severity of these complications were also examined. The indications for CUD were multiple medical comorbidities, a history of extensive prior bowel surgery, and solitary kidney. When asked for clarification, Dr. Antonio described the rationale for CUD in solitary kidney as concern for short life expectancy in these patients, who made up a full 15% of the cohort. In patients with two kidneys, the ureters were brought up separately to the skin, and all patients were left with indwelling ureteral stents which were changed on a monthly basis indefinitely.
As expected, the patient population was heavily weighted toward patients with significant preoperative comorbidity, with 58% of patients being ASA class III and 12% ASA class IV preoperatively. 231 of 365 patients had T3 or T4 tumors. The median age was 76 and the median BMI was 26. This low median BMI is notable, as patients with thick abdominal walls who would otherwise be good candidates for cutaneous ureterostomy will often be precluded from this kind of diversion due to inadequate ureteral length.
The primary result of the trial was the demonstration of an overall complication rate of 67% and a rate of complications greater than or equal to 3a of 12%. This was driven almost entirely by anemia requiring postoperative blood transfusion (grade 2, 51% of patients), with the second most common complication being ileus at 5%. There were 4 deaths, 10 grade 4 complications, and 31 grade 3 complications. The median time of hospitalization in this trial was 14 days. The authors concluded that “Cutaneous ureterostomy urinary diversion in patients undergoing radical cystectomy for bladder cancer is a valid surgical option...”
Establishing a prospective cohort of 365 patients who have undergone CUD is truly impressive, and it is useful to know that the procedure is being performed with overall low short term complication rates at these centers, however it is hard not to be a little disappointed coming away from this presentation does little to attempt to live up to its title by defining “The role of cutaneous ureterostomy diversion” in radical cystectomy. Hopefully, future work will do more with this valuable data, perhaps with the addition of a matched comparison group or reporting of more granular and longer-term data on factors like patient quality of life, stomal complications, ureteral stricture rate, etc.
Presented by: Nacchia Antonio, MD, Department of Urology, Ospedale Sant'Andrea, Sapienza University of Rome, Rome, Italy
Written by: Marshall Strother, MD, Chief Resident, Division of Urology, University of Pennsylvania, Philadelphia PA at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois